Month: March 2026

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Case 64: Ocular emergencies: A case of macula-on retinal detachment seen on POCUS  

Theresa Jo Thomas , Akash Desai

Case: A 49-year-old female with a past medical history of type 1 diabetes on insulin and myopia presented to the emergency department for vision changes. The patient stated that three days ago she noticed “flashers” in the vision of her right eye which she described as “squiggly lines”. The patient stated that on the day of her presentation to the emergency department at 1100 she noticed the bottom half of her vision as “grayed out” when looking to the ground. She stated that the grey vision was not present when looking upwards. The patient denied trauma to the eye, recent illness, eye pain, or eye irritation.   

Vitals : BP 129/87 HR 99 RR 17 SpO2 100% T 97.2 F  

Physical Exam: 

HEENT: Bilateral pupils equal, round, and reactive to light. Bilateral eyes without conjunctival injection, no hyphema or hypopyon. No pain with extraocular movements and extraocular movements intact. No notable trauma to orbit, no orbital bruising or tenderness.    Visual acuity was measured as below:

  • OD 20/50 Uncorrected 
  • OS 20/25 Uncorrected 
  • OU 20/50 Uncorrected 
  • OD 20/50 Corrected 
  • OS 20/30 Corrected 

Given patient’s concerning presentation, a bedside ocular ultrasound was performed to help further differentiate the patient’s complaint. 

Figure 1. Ocular ultrasound. Detached retinal membrane (R). The membrane is shown to be attached at the macula (M), lateral to the optic nerve (ON) which can be identified due to its characteristic nerve sheath shadow in the far field of the image.  
Figure 2. Ocular ultrasound clip with evidence of retinal detachment with macula-on. Ultrasound performed with linear array transducer in the longitudinal plane. The detached hyperechoic, serpiginous membrane, in a vertical orientation, seen on the left side of the image in the posterior chamber is indicative of a retinal detachment. Notice here that the detachment edge begins lateral to the macula. Due to a temporary PACS connectivity issue at the time of scanning, the ultrasound images were documented via mobile device recording of the screen rather than direct export. This explains the presence of motion artifact and reduced image fidelity in the attached clip. 
Figure 3. Differentiating between retinal detachment, posterior vitreous detachment, and vitreous hemorrhage with POCUS.  Source: POCUS 101

ED Course  

Ophthalmology was urgently consulted for concern for macula-on retinal detachment on bedside ultrasound. The patient was seen in the ED by ophthalmology who confirmed the diagnosis of macula-on retinal detachment, and the patient was scheduled for retinal surgery to occur later the same day. The patient was instructed to maintain NPO status and was discharged in hemodynamically stable condition to present to surgery as scheduled later that day.   

Discussion  

This case highlights the utility of POCUS in the diagnosis of retinal detachment. The presentation can vary, with patients often reporting an acute painless loss of vision or flashes and floaters [2]. Additional differential diagnoses include vitreous hemorrhage and posterior vitreous detachment, both of which can be identified on ultrasound. Retinal detachment is an ophthalmological emergency, while vitreous hemorrhage and posterior vitreous detachment can typically be managed with urgent outpatient follow-up with ophthalmology [2]. Thus, the diagnosis of retinal detachment is a time-sensitive diagnosis. The diagnosis of retinal detachment is typically made with dilated direct and indirect fundoscopic exams.  

When performing ocular ultrasound for this purpose, the linear array transducer should be used to obtain both transverse and longitudinal views of the eye. The patient should be instructed to move the eye superiorly and inferiorly as well as horizontally while examining with ultrasound [3]. The finding of interest suggesting retinal detachment is the presence of a retinal flap [4].  If the membrane flap is attached in the posterior globe and does not cross the optic nerve, this is suggestive of retinal detachment. This is typically a thicker, more hyperechoic flap than what is seen with a vitreous detachment [3]. Vitreous detachments, on the other hand, can cross the midline and are not tethered to the optic disc [3]. Should the retinal detachment be visualized extending temporally from the base of the optic nerve, near the approximate location of the macula, it is suggestive of macula off retinal detachment [3].  Conversely, lack of visualization of a retinal flap in the area of the macula is suggestive of macula-on retinal detachment.  

Ocular POCUS has been shown to diagnose retinal detachment reliably and accurately in the emergency department [5]. The standard of care includes urgent ophthalmology consultation as this problem is typically surgically managed to maximize vision preservation. Of note, macula-on retinal detachments have far better visual prognosis than macula-off retinal detachments, highlighting the importance of POCUS in facilitating early detection and vision-saving intervention.  Specifically, in macula-on cases, timely repair offers an opportunity to preserve central vision before permanent loss occurs, highlighting the value of ultrasound in distinguishing macula-on from macula-off detachments. It has been shown that emergency physicians can reliably exclude vitreous hemorrhage and detachment when performing POCUS to evaluate for retinal detachment [2]. We demonstrate here a case of macula-on retinal detachment identified on POCUS by an emergency physician.    

  

References  

  1. POCUS 101. Ocular ultrasound pocket card [Internet]. POCUS 101; 2020 Aug [cited 2026 Jan 6]. Available from: https://pocus101.b-cdn.net/wp-content/uploads/2020/08/POCUS-101-Ocular-Ultrasound-Pocket-Card.pdf 
  2. Lahham S, Shniter I, Thompson M, Le D, Chadha T, Mailhot T, Kang TL, Chiem A, Tseeng S, Fox JC. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Netw Open. 2019 Apr 5;2(4):e192162. doi: 10.1001/jamanetworkopen.2019.2162. PMID: 30977855; PMCID: PMC6481597.   
  3. Situ-LaCasse E, Adhikari SR. Ocular emergencies. Sonoguide [Internet]. American College of Emergency Physicians; 2020 Aug 18 [cited 2026 Jan 6]. Available from: https://www.acep.org/sonoguide/advanced/ocular-emergencies 
  4. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010 Sep;17(9):913-7. doi: 10.1111/j.1553-2712.2010.00809.x. PMID: 20836770. 
  5. Vrablik ME, Snead GR, Minnigan HJ, Kirschner JM, Emmett TW, Seupaul RA. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med. 2015 Feb;65(2):199-203.e1. doi: 10.1016/j.annemergmed.2014.02.020. Epub 2014 Mar 27. PMID: 24680547.  

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          Case 63:  Point-of-Care Ultrasound in Inferior Glenohumeral Dislocation (Luxatio Erecta) 

          Makhlouf Bannoud, Colleen Campbell

           A 22-year-old male with no significant past medical history presented to the emergency department with right shoulder pain and visible deformity after a surfing injury. He reported that a wave forcefully pulled his surfboard while he was holding on, followed by an audible “pop.” He denied head trauma, distal numbness, weakness, or additional injuries. 

          Vitals: BP 151/81 | HR 104 | RR 27 | Temp 97.8°F (36.6°C) | SpO₂ 93% 

          On exam, the patient was in acute discomfort but alert and oriented. The right upper extremity was held in abduction with visible deformity and inferior displacement of the humeral head. Distal neurovascular exam demonstrated 2+ radial pulse, intact sensation in the axillary, median, radial, and ulnar distributions, and full motor strength in the hand. 

          Point-of-care ultrasound (POCUS) of the right shoulder was performed prior to radiography to evaluate the glenohumeral joint. Ultrasound demonstrated inferior displacement of the humeral head relative to the glenoid fossa, consistent with inferior glenohumeral dislocation (Figure 1). No obvious joint effusion or cortical step-offsuggestive of displaced fracture was visualized. 

          Figure 1: Inferior shoulder dislocation with humerus outside the glenoid fossa.

           Ultrasound guidance was then used to perform an intra-articular anesthetic injection for analgesia prior to reduction (Figure 2).

          Figure 2: Ultrasound-guided joint injection.

          Moderate procedural sedation with propofol was subsequently administered. Closed reduction was performed successfully. 

          Post-reduction POCUS demonstrated restoration of normal alignment between the humeral head and glenoid (Figure 3). 

          Figure 2: Post-reduction ultrasound.

          Follow-up radiographs confirmed interval reduction and revealed a Hill-Sachs deformity without definitive osseous Bankart lesion. Repeat neurovascular examination remained intact. The patient was placed in a sling and discharged with close orthopedic follow-up. 

          Discussion 

          Inferior glenohumeral dislocation, or luxatio erecta, accounts for less than 1% of shoulder dislocations [1]. The classic mechanism involves hyperabduction, driving the humeral head inferior to the glenoid fossa. Patients typically present with the arm fixed in abduction and inability to adduct the limb. 

          Although radiographs remain standard for definitive diagnosis, point-of-care ultrasound has emerged as a reliable adjunct for rapid diagnosis of shoulder dislocation. Multiple studies have demonstrated high sensitivity and specificity approaching 100% for identifying glenohumeral dislocation [2]. Ultrasound allows dynamic assessment without radiation and can expedite care in high-volume emergency settings. 

          The posterior transverse view is most commonly used, with the probe placed over the scapular spine to visualize the glenoid and humeral head relationship. In normal alignment, the humeral head appears centered over the glenoid. In inferior dislocation, the humeral head is displaced caudally relative to the glenoid, as demonstrated in this case. 

          POCUS also facilitates ultrasound-guided intra-articular anesthetic injection. Compared to landmark-based techniques, ultrasound guidance improves accuracy of joint entry and reduces complications [3]. Intra-articular lidocaine has been shown to be comparable to intravenous sedation in facilitating reduction, with shorter ED length of stay and fewer adverse events [4].

          In this case, ultrasound-guided anesthetic injection was used as adjunctive analgesia prior to procedural sedation. Vascular injury, although rare, may involve the axillary artery. For this reason, careful pre- and post-reduction neurovascular examination is essential. 

          Associated injuries are common and include Hill-Sachs deformity, greater tuberosity fracture, rotator cuffinjury, and labral tears. [5] Post-reduction imaging in this case demonstrated a Hill-Sachs lesion, which may predispose young active patients to recurrent instability depending on lesion size and engagement. 

          This case highlights the expanding role of point-of-care ultrasound in musculoskeletal emergencies. POCUS enabled rapid confirmation of inferior glenohumeral dislocation, guided intra-articular anesthetic injection, and verified successful reduction prior to radiographic confirmation. When integrated thoughtfully into clinical workflow, ultrasound enhances procedural safety, diagnostic efficiency, and patient comfort in the management of shoulder dislocation. 

          References: 

          [1] StatPearls. (2023). Inferior shoulder dislocations. In StatPearls [Internet]. StatPearls Publishing. Retrieved October 2025, from https://www.ncbi.nlm.nih.gov/books/NBK448196/ 

          [2] Gottlieb, M., Holladay, D., & Peksa, G. D. (2019). Point-of-care ultrasound for the diagnosis of shoulder dislocation: a systematic review and meta-analysis. The American Journal of Emergency Medicine, 37(4), 757-761. 

          [3] Aly, A. R., Rajasekaran, S., & Ashworth, N. (2015). Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British journal of sports medicine, 49(16), 1042-1049. 

          [4] Sithamparapillai, A., Grewal, K., Thompson, C., Walsh, C., & McLeod, S. (2022). Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. Canadian Journal of Emergency Medicine, 24(8), 809-819. 

          [5] Ostermann, R. C., Joestl, J., Hofbauer, M., Fialka, C., Schanda, J. E., Gruber, M., ... & Tiefenboeck, T. M. (2022). Associated pathologies following luxatio erecta humeri: a retrospective analysis of 38 cases. Journal of Clinical Medicine, 11(2), 453. 

          [6] Flinders, A., & Seif, D. (2016). Point-of-Care Ultrasound in Diagnosis and Treatment of Luxatio Erecta (Inferior Shoulder Dislocation). Journal of Medical Ultrasound, 24(2), 70-73 

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          Case 62: Undifferentiated Hypotension in the setting of Atrial Fibrillation with Rapid Ventricular Response

          Lucia Hong, Elaine Yu

          A 70-year-old male with a history of cirrhosis, COPD, HTN, T2DM, and large abdominal wall hernia who presented after being found down in his home by a neighbor. Upon arrival, the patient was hypotensive with systolic blood pressures in the 70s and in atrial fibrillation with RVR with heart rates in the 170s. He received 500mL intravenous fluids prior to arrival and was transported on supplemental oxygen. The patient was altered and unable to provide history.

          On physical examination, the patient appeared acutely ill and minimally responsive. Mucous membranes were dry. Cardiovascular examination demonstrated tachycardia with an irregular rhythm. Lung examination revealed bilateral breath sounds without focal wheezes or stridor. The abdomen was distended with generalized tenderness and a large non-reducible abdominal wall hernia. Extremities were warm and perfused without significant peripheral edema. Neurologic examination demonstrated altered mental status with intermittent command following and spontaneous movement of all extremities.

          Synchronized cardioversion was performed following sedation with fentanyl and midazolam, which resulted in sinus tachycardia with improvement in heart rate and blood pressure.

          Vital Signs: BP: 94/62 | HR: 102 | RR: 25 | Temp: 100 °F| SpO₂: 99% on 5L O2

          Following cardioversion, RUSH was performed with findings of a small pericardial effusion, a plethoric inferior vena cava with minimal respiratory variation, and abnormal right ventricular wall motion with apparent right ventricular enlargement (Figure 1).

          Additionally, intra-abdominal free fluid concerning for ascites was also seen (Figure 2). These findings prompted further evaluation of cardiogenic, obstructive, and distributive shock.

          Figure 1. Apical 4-chamber view showing right ventricular enlargement with wall motion abnormality characterized as hypokinesia of the right ventricular free wall and contraction at the apex.1

          Figure 2. Abdominal ultrasound showing large ascites in the left lower quadrant.2

          Labs: WBC 13.3, Hgb 6.9, lactate 2.1, troponin 192 -> 189, D-dimer 26,069

          Imaging

          CTA PE: No definite pulmonary embolism. Mild volume overload, probably cardiogenic.

          CT Abdomen/Pelvis with contrast: 4.7 cm left anterior bladder wall abscess. Large volume ascites.

          Discussion

          Undifferentiated hypotension in the emergency department presents a diagnostic challenge, particularly in patients with multiple comorbidities and competing etiologies of shock. Rapid Ultrasound in Shock and Hypotension (RUSH) examination has emerged as a critical bedside tool allowing evaluation of physiologic contributors to shock prior to definitive diagnostic testing. The RUSH protocol integrates focused cardiac, vascular, pulmonary, and abdominal ultrasound assessment to assess hypovolemic, distributive, cardiogenic, or obstructive etiologies.3 Incorporation of early bedside ultrasound has been shown to alter the presumed category of shock in up to 50% of patients presenting with nontraumatic hypotension.4 RUSH is associated with faster diagnostic clarification and earlier targeted therapy in critically ill emergency department patients.5 The utilization of POCUS has demonstrated high specificity for detecting right ventricular strain patterns associated with obstructive shock states.6 Furthermore, POCUS can improve evaluation of volume status and reduce potentially harmful fluid overload in critically ill patients.7

          In this case, the patient presented with hypotension, altered mental status, and atrial fibrillation with RVR. Multiple or mixed shock etiologies were plausible, including septic shock from intra-abdominal infection, cardiogenic shock related to arrhythmia or myocardial injury, and obstructive shock with pulmonary embolism. Additionally, hypovolemia was also considered given an initial Hgb 6.9. Identification of right ventricular wall abnormalities increased clinical suspicion for obstructive pathology, and a subsequent D-dimer was noted to be significantly elevated. CTA PE was completed that ruled out pulmonary embolism and demonstrated volume overload from a likely cardiogenic cause. Further CT images identified a bladder abscess as a source of sepsis. Additionally, RUSH examination findings contributed to cautious fluid administration and prompted consideration of alternative shock mechanisms.

          This case highlights how POCUS guides subsequent decision-making. As emphasized in current American College of Emergency Physicians guidelines, POCUS serves as an extension of the physical examination and plays an increasingly central role in the early evaluation of critically ill patients in the emergency department.8

          References

          1. Kansara T, Quesada F, Park H, Ghosh K, Saeed M. McConnell’s Sign Still Holds Its Value: A Lesson Learned From Two Cases. Cureus. 2019;11(11):e6240. doi:10.7759/cureus.6240

          2. Zuidewind P. Cirrhosis and portal hypertension. Case study, Radiopaedia.org. Published June 21, 2020. https://radiopaedia.org/cases/cirrhosis-and-portal-hypertension-1

          3. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28(1):29–56.

          4. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004;32(8):1703–1708.

          5. Atkinson PRT, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? A systematic review and meta-analysis. Resuscitation. 2018;127:1–9.

          6. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950–957.

          7. Marik PE, Monnet X, Teboul JL. Hemodynamic Parameters to Guide Fluid Therapy. Ann Intensive Care. 2011;1:1.

          8. American College of Emergency Physicians. Emergency Ultrasound Guidelines. Ann Emerg Med. 2017;69(5):e27–e54.

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